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Measures to guard against the infection work under the current assumption that SARS-CoV-2 is spread by respiratory droplets, although face masks are unlikely to prevent infection

A novel strain of coronavirus — SARS-CoV-2 — was first detected in December 2019 in Wuhan, a city in China’s Hubei province with a population of 11 million, after an outbreak of pneumonia without an obvious cause. The virus has now spread to over 200 countries and territories across the globe, and was characterised as a pandemic by the World Health Organization (WHO) on 11 March 2020[1],[2].

As of 9:00 on 4 June 2020, there were 6,416,828 laboratory-confirmed cases of coronavirus disease 2019 (COVID-19) infection globally, with 382,867 reported deaths. The number of cases and deaths outside of China overtook those within the country on 16 March 2020[3].

As of 9:00 on 4 June 2020, there have been 281,661 confirmed cases of the virus in the UK and, as of 17:00 on 3 June 2020, 39,904 of these have died (in all settings).

This article gives a brief overview of the new virus and what to look out for, and will be updated daily. It provides answers to the following questions:

What are coronaviruses?

SARS-CoV-2 belongs to a family of single-stranded RNA viruses known as coronaviridae, a common type of virus which affects mammals, birds and reptiles.

In humans, it commonly causes mild infections, similar to the common cold, and accounts for 10–30% of upper respiratory tract infections in adults[4]. More serious infections are rare, although coronaviruses can cause enteric and neurological disease[5]. The incubation period of a coronavirus varies but is generally up to two weeks[6].

Previous coronavirus outbreaks include Middle East respiratory syndrome (MERS), first reported in Saudi Arabia in September 2012, and severe acute respiratory syndrome (SARS), identified in southern China in 2003[7],[8]. MERS infected around 2,500 people and led to more than 850 deaths while SARS infected more than 8,000 people and resulted in nearly 800 deaths[9],[10]. The case fatality rates for these conditions were 35% and 10%, respectively.

SARS-CoV-2 is a new strain of coronavirus that has not been previously identified in humans. Although the incubation period of this strain is currently unknown, the United States Centers for Disease Control and Prevention indicate that symptoms may appear in as few as 2 days or as long as 14 days after exposure[6]. Chinese researchers have indicated that SARS-CoV-2 may be infectious during its incubation period[11].

The number of cases and deaths outside of China overtook those within it on 16 March 2020

Where has the new coronavirus come from?

It is currently unclear where the virus has come from. Originally, the virus was understood to have originated in a food market in Wuhan and subsequently spread from animal to human. Some research has claimed that the cross-species transmission may be between snake and human; however, this claim has been contested[12],[13].

Mammals such as camels and bats have been implicated in previous coronavirus outbreaks, but it is not yet clear the exact animal origin, if any, of SARS-CoV-2[14].

How contagious is COVID-19?

Increasing numbers of confirmed diagnoses, including in healthcare professionals, has indicated that person-to-person spread of SARS-CoV-2 is occurring[15]. The preliminary reproduction number (i.e. the average number of cases a single case generates over the course of its infectious period) is currently estimated to be between 1.4 to 2.5, meaning that each infected individual could infect between 1.4 and 2.5 people[16].

Similarly to other common respiratory tract infections, MERS and SARS are spread by respiratory droplets produced by an infected person when they sneeze or cough[17]. Measures to guard against the infection work under the current assumption that SARS-CoV-2 is spread in the same manner.

How is COVID-19 diagnosed?

As this coronavirus affects the respiratory tract, common presenting symptoms include fever and dry cough, with some patients presenting with respiratory symptoms (e.g. sore throat, nasal congestion, malaise, headache and myalgia) or even struggling for breath.

The case definition for COVID-19 is based on symptoms regardless of travel history or contact with confirmed cases. Diagnosis is suspected in patients requiring admission to hospital with signs and symptoms of pneumonia, acute respiratory distress syndrome or influenza, and in those with a new, continuous cough or fever who are well enough to stay in the community (see Box 1). A new symptom, a loss or changed sense of normal smell or taste (anosmia), was added on 18 May 2020. A diagnostic test has been developed, and countries are quarantining suspected cases[19].

Box 1: Who qualifies as a suspected COVID-19 case?

Patients who meet the following criteria (inpatient definition):

Those requiring admission to hospital AND

Those who have either clinical or radiological evidence of pneumonia OR

Acute respiratory distress syndrome OR

Influenza like illness (fever ≥37.8°C and at least one of the following respiratory symptoms, which must be of acute onset: persistent cough [with or without sputum], hoarseness, nasal discharge or congestion, shortness of breath, sore throat, wheezing, sneezing) OR

A loss of, or change in, normal sense of taste or smell (anosmia) in isolation or in combination with any other symptoms.

Clinicians should consider testing inpatients with new respiratory symptoms or fever without another cause or worsening of a pre-existing respiratory condition.

Patients who meet the following criteria and are well enough to remain in the community:

New continuous cough AND/OR

High temperature AND/OR

Anosmia (a loss or changed sense of normal smell or taste)

Individuals with a cough, fever or anosmia who live alone should now stay at home for 7 days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms.

Clinicians should be alert to the possibility of atypical presentations in patients who are immunocompromised. Alternative clinical diagnoses and epidemiological risk factors should be considered.

What social distancing measures are being taken in the UK?

The government launched its coronavirus action plan on 3 March 2020, which details four stages: contain, delay, mitigate, research[20]. On 12 March 2020, the UK moved to the delay phase of the plan and raised the risk level to ‘high’.

On 16 March 2020, Johnson said that the UK is “now approaching the fast growth part of the upward curve” and, without drastic action, cases could double every 5 or 6 days. He announced social distancing measures, such as working from home and avoiding social gatherings, as well as household isolation for those with symptoms[21],[22].

Further social distancing measures were announced on 18 March 2020, including closing all schools in the UK except for vulnerable children and those of key workers, such as pharmacists and other health and social care staff, teachers and delivery drivers. Restaurants, cafes, pubs, leisure centres, nightclubs, cinemas, theatres, museums and other businesses were also told to close.

On 22 March 2020, Johnson announced that the most clinically extremely vulnerable people, including those who have received organ transplants, are living with severe respiratory conditions or specific cancers, and some people taking immunosuppressants, should stay in their homes for at least the next 12 weeks (see Box 2). However, the government updated its advice on 31 May 2020, revealing that those who have been shielding can go outside with members of their own household from 1 June 2020; those who live alone can meet outside with one other person from another household.

Box 2: Shielding from COVID-19

Those classed as “clinically extremely vulnerable” may include the following (disease severity, history or treatment levels will also affect who is in this group):

Solid organ transplant recipients

People with specific cancers

People with cancer who are undergoing active chemotherapy

People with lung cancer who are undergoing radical radiotherapy

People with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment

People having immunotherapy or other continuing antibody treatments for cancer

People having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors

People who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs

People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe chronic obstructive pulmonary

People with rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency, homozygous sickle cell)

People on immunosuppression therapies sufficient to significantly increase risk of infection

Women who are pregnant with significant heart disease, congenital or acquired

A strict lockdown started in the UK on 23 March 2020, with people told to stay at home except to buy essential food and medicines, one form of exercise a day, any medical need, and travelling to and from essential work. Gatherings of more than two people in public was not allowed and all shops selling non-essential goods, libraries, playgrounds, outdoor gyms and places of worship closed. All social events, including weddings, baptisms and other ceremonies, but excluding funerals were cancelled.

A relaxation of the lockdown was announced by Johnson on 10 May 2020. The goverment published a 60-page ‘recovery strategy’ on 11 May 2020, which sets out the next phases of the UK’s response to the virus, including easing some social restrictions, getting people back to work and reopening schools.

What is happening with testing for COVID-19?

As of 4 June 2020, 5,005,565 tests for COVID-19 had been carried out in the UK. On 2 April 2020, health secretary Matt Hancock outlined plans to dramatically increase testing across the UK to 100,000 tests a day by the end of the month, a target that was initially met. The new target is 200,000 tests a day by the end of May 2020, which was exceeded on 30 May 2020.

Tests can now be accessed by anyone with symptoms in England and Scotland, and anyone over the age of five years with symptoms in Wales and Northern Ireland. Tests can be booked via nhs.uk/coronavirus.

An NHS test and trace service was launched across England on 28 May 2020, with similar services starting in Scotland and Wales around the same time. Anyone who tests positive for the virus is contacted to share information about their recent interactions. People identified as being in close contact with someone who tests positive will have to self-isolate for 14 days, regardless of whether they have symptoms.

Testing is also now available to care home staff and residents in England, and NHS workers where there is a clinical need, whether or not they have symptoms.

Pharmacy staff in England and Scotland should book tests online via gov.uk and they will be conducted at drive-through testing sites across the country, as well as via home testing kits.

Pharmacy staff in Wales with symptoms of COVID-19 are able to access testing through their Local Health Board.

The government has also announced the start of a new national antibody testing programme, with plans to provide antibody tests to NHS and care staff in England from the end of May 2020. Clinicians will also be able to request the tests for patients in both hospital and social care settings if they think it is appropriate.

What should I do if a patient thinks they have COVID-19?

Patients have been advised not to go to their community pharmacy if they are concerned that they have COVID-19. Those with a new, continuous cough or a high temperature or anosmia (a loss or changed sense of normal smell or taste) who live alone should self-isolate for seven days from the onset of symptoms. Households should all self-isolate for 14 days if one member shows symptoms[22]. There is no need for people with minor symptoms to telephone NHS 111 or to be tested for COVID-19.

However, given the outbreak has coincided with the cold and flu season, it is likely that patients may present in the pharmacy with queries about the virus, or with concerns about their cold or flu symptoms.

Community pharmacies were told by NHS England and NHS Improvement on 27 February 2020 that, in the unlikely event that a suspected case does present, they must prepare a “designated isolation space”[23].

If the pharmacy does not have a suitable room to isolate a suspected patient, an area that would keep a patient at least two metres away from staff and other patients in the pharmacy should be prepared so that it can be cordoned off.

Patients who present with a new, continuous cough or a high temperature or anosmia should be told to return home immediately and self-isolate. If, in the clinical judgement of the pharmacist, the person is too unwell to return home, they and any accompanying family should be invited into the designated isolation space where emergency services should be contacted.

The Royal Pharmaceutical Society is publishing ongoing guidance on contingency planning for COVID-19, which includes measures to protect the pharmacy team, such as limiting the number of people within the pharmacy at the same time, keeping at least two metres apart from staff and people coming into the pharmacy, and sectioning the pharmacy to encourage social distancing with floor markings (using tape) or barriers. The RPS has also produced a table to help pharmacists distinguish between COVID-19, a cold, the flu and hayfever.

The General Pharmaceutical Council said on 3 March 2020 that it recognises pharmacists may need to depart from established procedures in order to care for patients during the coronavirus outbreak and that regulatory standards are designed to be flexible and to provide a framework for decision-making in a wide range of situations.

In a joint statement with ten other health regulators, the GPhC said: “Where a concern is raised about a registered professional, it will always be considered on the specific facts of the case, taking into account the factors relevant to the environment in which the professional is working”.

What can I do to protect myself and my staff?

An updated standard operating procedure (SOP) for community pharmacies, published on 22 March 2020, sets out measures to protect pharmacy staff, including advising customers to keep a distance of at least two metres from other people, limiting entry and exit to the pharmacy and installing full screens to protect members of staff from airborne particles (see Learning article section ‘Enforcing social distancing’ for further details).

There has been some confusion around advice on personal protective equipment (PPE) for community pharmacists published by Public Health England. Guidance originally published on 2 April 2020 was updated on 10 April 2020, to recommend that pharmacy staff should only wear PPE when in “contact with possible or confirmed cases of COVID-19”. The original version of the guidance simply stated that fluid-resistant (Type IIR) surgical masks (FRSM) were recommended if social distancing could not be maintained.

The updated guidance now states: “If social distancing of 2m is maintained there is no indication for PPE in a pharmacy setting. If social distancing is not maintained, though, direct care is not provided, sessional use of FRSM is recommended for contact with possible or confirmed cases of COVID-19”. Sessional use means for the duration of duties in a specific clinical care setting or exposure environment.

The guidance from PHE differs from that of the RPS, which says that pharmacy staff working in community pharmacies and general practice should wear FRSMs if they are unable to maintain a social distance of 2 metres from patients and staff, and emphasises that it is still important to try to maintain social distance when wearing surgical masks wherever possible. The RPS also advises that gloves, apron and surgical masks should be worn by staff in direct contact with a patient, for example, when a person is too unwell to go home and is being cared for in the designated isolation space.

Guidance has been issued by pharmacy organisations on how community pharmacies in England can accept patient returns of unwanted medicines while minimising risk to pharmacy teams. Since coronaviruses can survive on certain surfaces for up to five days, it recommends that all returns should be double bagged and placed directly in waste medicines bins. Controlled Drugs should be double bagged and placed in the CD cabinet for five days before denaturing. A suggested procedure is detailed within the guidance.

Staff who have symptoms of COVID-19, or live with someone experiencing symptoms, should stay at home. Those who fall into one of the vulnerable groups at particular risk of complications from COVID-19 should not see patients face-to-face, regardless of whether the patient has possible COVID-19. Remote working should be prioritised for these staff.

NHS staff from a black, Asian or minority ethnic (BAME) background and others who who may be particularly vulnerable to COVID-19 — including those working in community pharmacies — should be risk assessed. In a letter dated 29 April 2020, NHS England said that “emerging UK and international data” suggest that people from BAME backgrounds are “being disproportionately affected by COVID-19”.

The Faculty of Occupational Medicine later published a risk reduction framework — backed by NHS England — to assist with the risk assessments on 14 May 2020. This was updated on 28 May 2020 to include guidance from the Health and Safety Executive to “help organisations identify who is at risk of harm”.

What about ‘business as usual’ during the pandemic?

Pharmacies are on the frontline of the fight against coronavirus and demand for services is high. The updated standard operating procedure (SOP) for community pharmacies specifies that, if under significant pressure, pharmacies may adjust their opening hours to cope with demand.

A number of contractual services have been put on hold and others have been brought forward (see Learning article section ‘Adjusting opening hours and pharmacy services’ for further details).

On 24 March 2020, health secretary Matt Hancock announced that ‘NHS Volunteer Responders’ will help to deliver medicines to patients’ homes on behalf of community pharmacies in England (see Learning article section ‘Communicating with patients’ for further details). Community pharmacies are expected to ensure that the 1.5 million patients who are shielding from COVID-19 (see Box 2) are able to receive their prescription medicines, either through friends and family or volunteers, or via an advanced pandemic delivery service that is being commissioned by NHS England and NHS Improvement from 9 April 2020. Pharmacies will be paid a monthly allowance as well as a payment per delivery for the advanced service.

In Wales, the government is identifying a cohort of DBS checked volunteers through British Red Cross to help vulnerable people with no existing social network to obtain medicines supplies. One volunteer with be “buddied up” with each community pharmacy and available, if needed, to provide an additional 10 deliveries each day. A logistics software package, Pro Delivery Manager (PDM), will be installed in community pharmacies to provide an audit trail for medicines, and assist with scheduling of delivery routes. It is, the Welsh government said, appropriate for patients to nominate their own community volunteer to collect their medicines. The Welsh government will cover the cost of the Pro Delivery licences, and also six months of expenses for volunteers’ expenses: although this may be extended. Community pharmacies in Wales are also working with the Royal Mail to ensure patients who are shielding or self-isolating receive their medicines during the COVID-19 pandemic.

The Scottish government has worked with Community Pharmacy Scotland (CPS) to make arrangements for delivery to shielded patients, and together they have developed a flow chart to help decide how to support these patients. If a shielded patient currently has no “prescription buddy”, and if their pharmacy is not able to make deliveries, then volunteers from local humanitarian hubs across each local authority area will step in, as part of a medicines collection service being developed by the government, CPS and health and social care partnerships. Volunteer drivers will need to be Disclosure Scotland checked, and patients will need to give consent to be included in the volunteer delivery service.

The General Pharmaceutical Council has stopped all routine inspections of pharmacies and submission of revalidation records has been postponed.

On 26 March 2020, the GPhC announced that the pharmacy pre-registration assessments for June and September 2020 have been postponed and will be rescheduled for the end of 2020, or early in 2021.

More than 6,200 pharmacy professionals who left the register within the past three years have been given temporary registration so that they can to return to work during the COVID-19 pandemic, if they wish to do so. And in guidance published on 9 April 2020, final year pharmacy students were told they can join their arranged preregistration workplace ahead of the scheduled start date to help deal with the COVID-19 pandemic.

Will the government provide financial help during the pandemic?

The PSNC announced on 31 March 2020 that community pharmacies in England will be given cash advances totalling £300.0m over the next two months to help with cashflow during the pandemic, but no extra funding has been negotiated so far. On 28 May 2020, the PSNC announced that community pharmacies will receive a further £50m of advance funding from the government on 1 June 2020. As with the £300m previously announced, the £50m is not additional funding and will be reconciled in 2020/2021.

Advance payments have also been agreed for community pharmacies in Scotland and Wales.

Additional funding of an initial £5.6m was agreed in Scotland on 7 April 2020 to support unparalleled levels of activity within community pharmacy during the pandemic. The funding will cover equipment costs, adaptations to premises, additional staffing and locum fees.

On 2 April 2020, the government announced that it had written off £13.4bn of debt as part of a major financial reset for NHS providers.

How can cross-infection be prevented?

The WHO has created a range of infographics to illustrate how patients can protect themselves and others from getting sick; however, most of the advice is similar to what would be provided for colds and flu (see Figure)[24].

There is no specific treatment for COVID-19. Although vaccines can be developed to treat viruses, owing to the novel nature of this infection, no vaccine has currently been developed and the process to develop one may take 12 to 18 months[18]. As an example, many antiviral agents have been identified to inhibit SARS in vitro, but there are currently no approved antiviral agents or vaccines available to tackle any potential SARS or SARS-like outbreaks, such as MERS or SARS-CoV-2[25].

There has been a lot of talk in the news and on social media about how certain medications can exacerbate the symptoms of COVID-19, what is the current advice around these medications?

The advice was issued following concerns circulated on social media that these medicines could predispose them to adverse outcomes should they become infected with COVID-19.

Both societies recommended that patients taking these medicines who present as unwell, or with a suspected or known COVID-19 infection, should be assessed on an individual basis and their medication managed according to established guidance. Inappropriate cessation of therapy could lead to a decline in control of blood pressure, heart failure or any other condition the individuals takes these medicines for.

Similar concerns have also arisen around the use of ibuprofen following unverified claims, backed by Oliver Veran, France’s health minister, that ibuprofen may exacerbate symptoms of the virus.

On 14 April 2020, the Committee of Human Medicines (CHM) — an advisory body of Medicines and Healthcare products Regulatory Agency — and the National Institute for Health and Care Excellence both published reviews, which concluded that there is insufficient evidence to establish a link between use of ibuprofen, or other NSAIDs, and susceptibility to contracting COVID-19 or the worsening of its symptoms.

A rapid policy statement published by NHS England on the same date, highlighted that there had been some reports of possible adverse effects of the use of NSAIDs in acute respiratory tract infections more generally, which had led to suggestions to use paracetamol preferentially for fever/pain in such situations. However, it said that there was currently no evidence that the acute use of NSAIDs caused an increased risk of developing COVID-19 or of developing a more severe COVID-19 disease.

Where can I find information on managing COVID-19 patients?

The Royal Pharmaceutical Society has collated resources for hospital pharmacists on the clinical management of patients with COVID-19, including treatments, use of experimental therapies, and evidence-based summaries.

The resources also include information on critical care services during the pandemic and guidance on COVID-19 in special populations, such as children, pregnant women, patients taking warfarin and those with cancer, respiratory conditions, diabetes, rheumatological conditions and HIV.

NHS England has published several “specialty guides” aimed at specialists working in hospitals during the pandemic. The guides cover areas such as adult critical care, cancer, musculoskeletal, children, general medicine and palliative care.

Is the coronavirus pandemic likely to precipitate medicines shortages?

The government banned the parallel export of chloroquine, as well as the antiretroviral lopinavir/ritonavir, on 26 February 2020 because they are being tested as possible treatments for COVID-19. There has been a lot of attention in the media on the potential benefits of chloroquine and hydroxychloroquine in treating patients with COVID-19 but the Medicines and Healthcare Regulatory Agency has warned that these medicines are not licensed to treat COVID-19 related symptoms or prevent infection and, until there is clear, definitive evidence that these treatments are safe and effective for the treatment of COVID-19, they should only be used for this purpose within a clinical trial.

On 20 March 2020, the government banned from parallel export more than 80 medicines used to treat patients in intensive care units. The restrictions cover crucial medicines such as adrenaline, insulin, paracetamol and morphine and are designed to prevent medicines shortages. A further 52 medicines, including a number of respiratory medicines, antibiotics, analgesics and insulin products, were banned from export on 1 April 2020. And a further 33 medicines were banned from export on 24 April 2020, including further respiratory medicines and some drugs that are being trialled for COVID-19, such as azithromycin, dexamethasone, ruxolitinib, sarilumab and tocilizumab.

Community pharmacists have been experiencing huge demand for paracetamol and many have reported shortages of paracetamol tablets 500mg as pharmacy and general sales list packs. The National Pharmacy Association and the GPhC have both said that pharmacies are able to break down larger packs to prepare supplies of a non-prescription items for retail sale.

Shortages of Chiesi’s Clenil and Fostair inhalers, along with inhalers from other brands, have been noticed by pharmacists as patients begin to panic and order inhalers they potentially do not need. The wholesaler AAH Pharmaceuticals placed 11 inhalers on its “out of stock” list on the 30 March 2020. NHS England wrote to healthcare professionals working in primary care on 31 March 2020, asking them not to overprescribe or over-order during this time, as this will create further pressures on the supply chain.

Are there national clinical trials of potential drugs to treat covid-19?

There are no antiviral medicines currently approved to treat or prevent COVID-19 and no randomised controlled trial evidence that any treatment beyond best supportive care delivers improved outcomes for patients.

However, there are three major randomised controlled trials of medicines to treat COVID-19 being funded by the UK government: PRINCIPLE, RECOVERY and REMAP-CAP (see Feature), and several other trials are being nationally prioritised.

In addition, on 28 April 2020, the Accelerating COVID-19 Research & Development (ACCORD) platform was launched, a collaboration between government, industry and research organisations that aims to reduce the time taken to set up clinical studies for new COVID therapies from months to weeks. ACCORD will rapidly test potential drugs through early stage clinical trials and, if they show promise, will feed them into the UK’s large-scale COVID-19 studies, such as RECOVERY. Bemcentinib, an AXL kinase inhibitor, will be the first to begin phase II studies across the UK within the next few days.

Further potential treatments will be rapidly fed into ACCORD as the programme rolls out over the next few weeks.

A Yellow Card website dedicated to reporting side-effects or incidents from medicines being used to treat COVID-19 has been set up by the Medicines and Healthcare products Regulatory Agency (MHRA).

WHAT TO DO IF THERE IS A RISK OF EXPOSURE TO THE VIRUS?• Respect the incubation period and stay in quarantine, symptoms can take up to 14 days to appear;• At the first symptoms such as fever, cough or dyspnea, call 15 directly;• Do not go directly to your GP or to the emergency room;• Wear a spray mask to protect your surroundings;• Avoid human contact, especially with frail people (children, the elderly, immunocompromised, pregnant women);• Stay home until you heal.

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